Vertigo David Clark, DO

Oregon Neurology Associates

Springfield, OR

44F vertigo, nausea &

vomiting

Unidirectional Nystagmus

44F vertigo, nausea &

vomiting

Impaired VOR Gain to the right

Vertigo

• History

• Anatomy/Physiology

• Horses

• Zebras

• Acute management

The Dizzy Bubble

Vertigo

Sleep

Disorder Gait

imbalance

Medication

Effect

Psychiatric

Depression

Anxiety

Panic Anemia

Hypertension

Hypo/hypergl

ycemia

Orthostatic

hypotension

Patient may have

difficulty articulating

their experience clearly

History Tips

• Quality of symptom not very helpful

• Dizzy, Vertigo, Light headed

• Symptom duration helps narrow DDx

• Associated symptoms helpful

• Nausea

• Tinnitus

• Diplopia

• Focal neurologic deficits

Differential by

Symptom Duration

Seconds Minutes Hours Days--Constant

Ischemic (TIA,Stroke)

BPPV**

Migraine

Vestibular

Neuritis

Demyelinating

Menieres

Mass lesion

Perilymphatic

fistula

SSCC dehiscence

**BPPV may be perceived as lasting hours-days

Peripheral vs. Central

Tonic firing from each peripheral

vestibular apparatus

Tonic firing from each

peripheral vestibular apparatus

Pathophysiology of vestibular symptoms and signs: The clinical examination,

DS Zee Neurology Continuum Aug 2006 pg 18

Tonic firing from each peripheral

vestibular apparatus

Asymmetry of the tonic firing tells

the brain there’s movement

Tonic firing from each

peripheral vestibular apparatus

Lesion or overaction

(BPPV) of the peripheral

vestibular aparatus or its

central connections

creates asymmetry of

tonic input and the

sensation of movement

BPPV

~3% population

• Vertigo lasts seconds to

minutes

• Provoked by head rotation

• Roll over in bed

• Look over shoulder

• Nausea/Vomiting

• Queasy for hours in

between

85-90%

Dix Hallpike

Semin Neurol. 2009;29(5):500-508.

Dix-

Hallpike

and Epley

(Steps 1-5)

Semin Neurol. 2009;29(5):500-508.

Diagnosis

and

treatment for

Right

Posterior

Canal BPPV

Epley

Video

Semont For Right posterior canal BPPV

Semin Neurol. 2009;29(5):500-508.

BPPV

• No central mimics of DH nystagmus

• Surgery

• Avoid chronic vestibular suppressants

Vestibular

Neuritis

• Unidirectional

nystagmus

• VOR Gain

• Steroids and

antivirals

VOR Gain Neurology 2011;76;e71

Vestibular Nystagmus

Vestibular neuritis

Slow Phase

Menieres

• Vertigo lasting minutes to hours

• Unilateral aural fullness and

tinnitus

• Over time, low frequency

sensorineural hearing loss

• Treat: diuretics, +/- steroids

• Intractable: intratympanic

gentamycin, surgery

Migrainous Vertigo,

~1% population

1. History of Migraine

2. ≥1 migraine symptom during ≥2 episodes of vertigo

1. HA

2. Photophobia

3. Phonophobia

4. Visual aura

3. No better explanation for vertigo

4. Treat migraine

MS

Diplopia

and

vertigo

Lung

adenocarcinoma

metastasis

Visually mediated dizziness

Post concussive

Migraine

Prior vertigo

Vestibular Schanomma

Superior semicircular canal

dehiscence Valsalva induced vertigo

Perilymphatic fistula

NEJM 366;4

Perilymphatic fistula Test

Can also see Tulio phenomenon

Vertebral artery

dissection and

cerebellar infarct

Bilateral Vestibular Loss

• Etiologies

• Aminoglycosides

• Irradiation

• Paraneoplastic

• Idiopathic

• B/L VOR gain

• Dynamic Visual Acuity

• Can’t read and walk

• No vertigo if symmetric

Static acuity

20/20

Dynamic acuity

20/100

Bilateral Vestibular Loss

• CANVAS

• Cerebellar ataxia

• Neuropathy

• Vestibular areflexia

Visual dizziness

Tardive dizziness following

lesion to Mollaret’s Triangle Red

Nucleus

Inferior

Olive

Dentate

Distinguishing central from peripheral

Peripheral

– Head impulse test: Abnormal

– Unidirectional nystagmus

– No vertical misalignment

Central

– Head Impulse test: Normal

– Alternating nystgmus

– Skew deviation

Skew video

Take home

• Historical keys

• Exam tools

• Dix-Hallpike

• Head impulse test

• Perilymphatic fistula test

• Valsalva

• Epley

• Differentiating central from peripheral vertigo in the acute setting

Questions